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North American Spine Society Journal Dec 2023Traumatic pneumocephalus (TPC) following craniofacial injuries is common, but isolated TPC secondary to pneumorrhachis (PR) is the rare result of upward gas migration...
BACKGROUND
Traumatic pneumocephalus (TPC) following craniofacial injuries is common, but isolated TPC secondary to pneumorrhachis (PR) is the rare result of upward gas migration from the spinal canal. In the absence of craniofacial and grossly unstable spinal fractures, the etiology of TPC in polytrauma can be elusive and an underlying diagnosis of acute spinal cord injury (SCI) can be easily missed. We report the first polytrauma case where TPC was the most reliable early sign of SCI.
CASE DESCRIPTION
A 34-year-old polytrauma female with imaging findings of TPC, which was later found to be secondary to an underlying SCI. As a focused exam could not be performed at admission, the TPC was first attributed to undiagnosed craniofacial injuries. Tertiary survey revealed the patient being paraplegic and MRI workup demonstrated an acute SCI at the T3-T4 level. PR was the most likely cause of TPC in the absence of other craniofacial injuries.
OUTCOME
The patient did not have a meaningful recovery given the extensive hemispheric infarcts, spinal cord injury, and respiratory failure.
CONCLUSIONS
Although uncommon, TPC may be an important radiographic sign suggesting the possibility of an underlying SCI in polytrauma patients. especially when focused neurologic assessment is limited at admission. Polytrauma patients with TPC and PR in the absence of coexisting craniofacial fractures require an urgent spine consultation by the ER physician, with possible early spine MRI workup. We suggest a diagnostic algorithm for the early identification of SCI in polytrauma patients presenting with TPC and propose considering 3 groups which may have different risks for SCI based on their clinical presentation and the presence of PR.
PubMed: 37942311
DOI: 10.1016/j.xnsj.2023.100281 -
Neurology India 2023
Topics: Humans; Pneumocephalus; Brain Injuries, Traumatic; Tomography, X-Ray Computed
PubMed: 37929482
DOI: 10.4103/0028-3886.388070 -
The Neuroradiology Journal Feb 2024We aimed to use machine learning (ML) algorithms with clinical, lab, and imaging data as input to predict various outcomes in traumatic brain injury (TBI) patients.
PURPOSE
We aimed to use machine learning (ML) algorithms with clinical, lab, and imaging data as input to predict various outcomes in traumatic brain injury (TBI) patients.
METHODS
In this retrospective study, blood samples were analyzed for glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCH-L1). The non-contrast head CTs were reviewed by two neuroradiologists for TBI common data elements (CDE). Three outcomes were designed to predict: discharged or admitted for further management (prediction 1), deceased or not deceased (prediction 2), and admission only, prolonged stay, or neurosurgery performed (prediction 3). Five ML models were trained. SHapley Additive exPlanations (SHAP) analyses were used to assess the relative significance of variables.
RESULTS
Four hundred forty patients were used to predict predictions 1 and 2, while 271 patients were used in prediction 3. Due to Prediction 3's hospitalization requirement, deceased and discharged patients could not be utilized. The Random Forest model achieved an average accuracy of 1.00 for prediction 1 and an accuracy of 0.99 for prediction 2. The Random Forest model achieved a mean accuracy of 0.93 for prediction 3. Key features were extracranial injury, hemorrhage, UCH-L1 for prediction 1; The Glasgow Coma Scale, age, GFAP for prediction 2; and GFAP, subdural hemorrhage volume, and pneumocephalus for prediction 3, per SHAP analysis.
CONCLUSION
Combining clinical and laboratory parameters with non-contrast CT CDEs allowed our ML models to accurately predict the designed outcomes of TBI patients. GFAP and UCH-L1 were among the significant predictor variables, demonstrating the importance of these biomarkers.
Topics: Humans; Retrospective Studies; Ubiquitin Thiolesterase; Brain Injuries, Traumatic; Prognosis; Biomarkers; Hospitals
PubMed: 37921691
DOI: 10.1177/19714009231212364 -
Case Reports in Otolaryngology 2023Eighty percent of cerebrospinal fluid leaks (CSF) occur following trauma and complicate 12 to 13% percent of all basilar skull fractures (Prosser, Vender, and Solares,...
Eighty percent of cerebrospinal fluid leaks (CSF) occur following trauma and complicate 12 to 13% percent of all basilar skull fractures (Prosser, Vender, and Solares, 2011). An endoscopic endonasal approach (EEA) is often the preferred method of repair with greater than 90% success rates (Prosser, Vender, and Solares, 2011). We report a case of a 37-year-old man who presented to our regional level 1 trauma centre with multiple facial injuries. Initial cross-sectional imaging revealed multiple, continuous anterior skull base fractures with associated pneumocephalus. Though initially managed conservatively, the patient represented five days later with unilateral left-sided rhinorrhoea. An endoscopic endonasal repair with a multilayer fat, tensor fascia lata, free mucosal graft, and vascularised local flap reconstruction was undertaken. This case highlights the importance of maintaining a high level of suspicion for delayed CSF leak in traumatic base of skull injury. The EEA enables meticulous dissection and thorough inspection of the skull base, facilitating multilayered repair and reconstruction of defects.
PubMed: 37841560
DOI: 10.1155/2023/6996215 -
The Journal of Emergency Medicine Dec 2023Pneumocephalus is defined as gas in the intracranial space. Common causes include head trauma, surgery, and diagnostic/therapeutic procedures resulting from the direct... (Review)
Review
BACKGROUND
Pneumocephalus is defined as gas in the intracranial space. Common causes include head trauma, surgery, and diagnostic/therapeutic procedures resulting from the direct disruption of the dura. Spontaneous or nontraumatic pneumocephalus is an uncommon condition, often caused by infection, either due to insidious disruption of the dura or gas-forming pathogens.
CASE REPORT
Herein, we report a rare case of spontaneous pneumocephalus associated with meningitis in a patient who received conservative treatment without surgical intervention. Blood culture revealed group A streptococcus. The pneumocephalus subsided gradually with antibiotic treatment, and no neurological deficits remained. A follow-up brain computed tomography scan showed the absence of pneumocephalus, but it showed progressive hydrocephalus. The patient was discharged on the 21st day of hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous pneumocephalus associated with meningitis is rare. It should always raise the suspicion of meningitis and prompt suitable treatment. Emergency physicians should always be vigilant for this particular possibility on brain computed tomography.
Topics: Humans; Pneumocephalus; Meningitis; Neuroimaging
PubMed: 37838493
DOI: 10.1016/j.jemermed.2023.06.013 -
Pediatric Emergency Care Nov 2023Mild traumatic brain injury (mTBI) comprises most (70%-90%) of all pediatric head trauma cases seeking emergency care. Although most mTBI cases have normal initial head...
OBJECTIVES
Mild traumatic brain injury (mTBI) comprises most (70%-90%) of all pediatric head trauma cases seeking emergency care. Although most mTBI cases have normal initial head computed tomography scan, a considerable portion of the cases have intracranial imaging abnormalities on computed tomography scan. Whereas other intracranial pathological findings have been extensively studied, little is known about the clinical significance of pneumocephalus in pediatric mTBI.
METHODS
We retrospectively identified pediatric mTBI patients with pneumocephalus using the institutional database of a large regional trauma referral center. Outcome measures were defined as clinically important TBI (ciTBI), hospitalization, intensive care unit (ICU) admission, and neurosurgical intervention. Comparisons were made between pneumocephalus and control (isolated linear fracture) groups as well as between isolated (only linear fracture and pneumocephalus) and nonisolated pneumocephalus (pneumocephalus and TBI) groups.
RESULTS
Among 3524 pediatric mTBI cases, 43 cases had pneumocephalus (1.2%). Twenty-one cases (48.8%) had isolated pneumocephalus. The pneumocephalus group had higher rates of ciTBI, hospital admission, ICU admission, and neurosurgery when compared with the isolated linear fracture (control) group. The isolated pneumocephalus group had fewer ciTBI (21.1% vs 70%, P = 0.002), fewer hospitalization (23.8% vs 81.8%, P < 0.001), but similar ICU admission rates (4.8% vs 22.7%, P = 0.089) and length of hospital stay (4.0 ± 2.7 vs 3.6 ± 2.4 days, P = 0.798) in comparison to the nonisolated pneumocephalus group. None of the patients in the isolated group had neurosurgery whereas 2 patients in the nonisolated pneumocephalus group underwent surgery. Multivariable analysis revealed pneumocephalus as an independent predictor of ciTBI and hospital admission, but not ICU admission or neurosurgical intervention.
CONCLUSION
Pneumocephalus is associated with increased rates of hospitalization and ciTBI, but not ICU admission, unfavorable outcome, or neurosurgical intervention in pediatric mTBI. Although usually spontaneously resolving pathology, it may occasionally be linked with complications such as cerebrospinal fluid leakage, meningitis, and tension pneumocephalus. Therefore, careful evaluation, close observation, and early detection of complications may prevent adverse outcomes.
Topics: Child; Humans; Brain Concussion; Pneumocephalus; Retrospective Studies; Clinical Relevance; Brain Injuries, Traumatic; Fractures, Bone
PubMed: 37815282
DOI: 10.1097/PEC.0000000000003060 -
Encephalitis (Seoul, Korea) Oct 2023Pneumocephalus refers to a pathologic collection of gas within the cranial cavity and is mostly caused by head trauma and neurosurgical procedures. Spontaneous...
Pneumocephalus refers to a pathologic collection of gas within the cranial cavity and is mostly caused by head trauma and neurosurgical procedures. Spontaneous nontraumatic pneumocephalus is a very rare condition. We herein report an unusual case of community-acquired bacterial meningitis with a combination of acute otitis media, Enterobacter cloacae, and nontraumatic pneumocephalus. A 75-year-old woman presented with fever, mental change, and neck stiffness. Brain imaging demonstrated pneumocephalus and fluid collection in the left mastoid air cells. E. cloacae was isolated from both blood and otorrhea cultures, and the patient was successfully treated with intravenous ceftazidime for 3 weeks. Although E. cloacae is a very rare cause of community-acquired bacterial meningitis in adults, it should be considered as a possible pathogen in otogenic meningitis complicated with pneumocephalus.
PubMed: 37743053
DOI: 10.47936/encephalitis.2023.00164 -
Journal of Neurosurgery. Case Lessons Sep 2023Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal...
BACKGROUND
Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory.
OBSERVATIONS
A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula.
LESSONS
Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever "otogenic" pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.
PubMed: 37728168
DOI: 10.3171/CASE23300 -
Cureus Aug 2023Pneumocephalus, or air entrapment within the cranium, is a rare but dangerous condition with a variety of causes, including trauma, surgery, or predisposing infection....
Pneumocephalus, or air entrapment within the cranium, is a rare but dangerous condition with a variety of causes, including trauma, surgery, or predisposing infection. Trauma is the most common etiology, as fractures provide easy access for air to become entrapped in the cranium. However, access such as via the central nervous system with leak exists. Though not as common as traumatic pneumocephalus, pneumocephalus secondary to infection is a dangerous condition. The literature is sparse on this example of ear-nose-throat infection, making it difficult to form and ascertain guidelines for the management of infectious pneumocephalus and its complications. A 58-year-old man with a history of hypertension, obesity, type 2 diabetes mellitus, and obstructive sleep apnea who presented with a complicated case of acute otitis media associated with subdural empyema, pneumocephalus, and group A Streptococcus is presented in this case report. We describe the course of his hospital stay, management, and current infectious disease guidelines. Given the paucity of cases of infectious pneumocephalus secondary to otitis media, we aim to provide further representation for this important illness as well as encourage the use of a multimodal team of providers. In our case, it was necessary to involve the ear-nose-throat specialist as well as infectious disease and neurocritical care services.
PubMed: 37727174
DOI: 10.7759/cureus.43756 -
Medical Gas Research 2024Nitrous oxide (NO) is a unique anesthetic agent that has both advantages and disadvantages, especially in neurosurgical patients. Various studies evaluating the use of... (Randomized Controlled Trial)
Randomized Controlled Trial
Nitrous oxide (NO) is a unique anesthetic agent that has both advantages and disadvantages, especially in neurosurgical patients. Various studies evaluating the use of NO in different surgical populations have been inconclusive so far. In this prospective, single-blinded, randomized study, 50 patients of either sex, aged 18-60 years, were enrolled and randomly allocated into NO or NO free group. Data including demographics, intraoperative vitals, blood gases, intravenous fluids, anesthetic drug consumption, brain condition, emergence and recovery time, duration of surgery and anesthesia, duration of postoperative ventilation, perioperative complications, condition at discharge, and duration of intensive care unit & hospital stay were recorded. There was no significant difference in intensive care unit or hospital stay between the groups. However, a significant difference in intraoperative heart rate and mean arterial pressure was observed. The incidence of intraoperative tachycardia and hypotension was significantly higher in the NO free group. Other intra- and post-operative parameters, perioperative complications, and conditions at discharge were comparable. Use of NO anesthesia for cerebellopontine tumor surgery in good physical grade and well-optimized patients neither increases the length of intensive care unit or hospital stay nor does it affect the complications and conditions at discharge. However, future studies in poor-grade patients with large tumors and raised intracranial pressure will be required to draw a definitive conclusion.
Topics: Humans; Nitrous Oxide; Sevoflurane; Anesthetics, Inhalation; Prospective Studies; Methyl Ethers; Anesthesia, Inhalation; Neoplasms
PubMed: 37721252
DOI: 10.4103/2045-9912.351105